Abstract
PURPOSE:
It is estimated that up to 80% of patients referred to outpatient physical therapy have diabetes, prediabetes, or diabetes risk factors; thus, physical therapists are in an optimal position to intervene as members of a multidisciplinary team working to effectively manage and reduce the diabetes epidemic. The purpose of this study is to assess the knowledge, practices, attitudes and beliefs of private practice physical therapists toward patients with prediabetes.
METHODS:
One thousand members of the Private Practice section of the American Physical Therapy Association were randomly selected through a random number generator to participate. Participants completed a paper based survey that was specifically designed for this study.
RESULTS:
Sixty-three physical therapists (34 males, 29 females; mean age: 52.8±11.5 years; mean number of years of clinical practice: 25.7±12.3 years) agreed to participate. The majority of participants (79%) agreed that identifying prediabetes in their patients is important; only 3% identified all of the risk factors that should prompt prediabetes screening. Seventy three percent of participants identified the correct laboratory test to screen for diabetes;<10% could identify the correct laboratory parameters for diagnosing prediabetes and diabetes. Only 2% and 22% of participants could identify correct weight loss and physical activity recommendations, respectively.
CONCLUSION:
A number of gaps in the knowledge of private practice physical therapists were noted in this study. These results may have important implications for the education of private practice physical therapists, especially those providing care for patients without a referral who are at risk for diabetes.
Introduction
The prevalence of diabetes has increased dramatically worldwide over the past few decades with extremely important social, financial and health system implications [1–3]. The number of people with diabetes in 2000 was 151 million; this rose to 415 million in 2015 (8.8% global prevalence), with 5.0 million deaths due to diabetes and a total global health expenditure estimated at 673 billion US dollars [1]. It is estimated that the number of people with diabetes will rise to 642 million (10.4% global prevalence) by 2040, with the number of deaths and health expenditures due to diabetes continuing to rise across the globe. Diabetes was the third leading cause of global disability in 2015 for individuals between the ages of 55 and 79 years [2]; thus, the intangible costs associated with diabetes, such as pain, suffering, and reduced quality of life, should also should be considered when describing the global burden of this disease [3].
Prediabetes is a high-risk state for diabetes that is characterized by glycemic variables that are higher than normal, but lower than the thresholds needed to diagnose diabetes [4]. Individuals with prediabetes are at a high risk of developing diabetes, with an estimated 70% of people with prediabetes eventually developing diabetes [4]. Thus, appropriate diagnosis and management of prediabetes is critical to effectively stem the rising incidence of diabetes. Many interventional strategies exist that can effectively reduce the risk of individuals with prediabetes developing diabetes, including weight loss, physical activity, and pharmacologic management [5].
Recently, Tseng et al. [6] assessed the knowledge, practices, attitudes, and beliefs toward prediabetes of 155 primary care providers associated with an academic system in the United States, including physicians (92.9%), nurse practitioners (6.4%), and physician assistants (0.7%). Tseng et al. [6] determined that only 6% of primary care providers correctly identified all of the risk factors that should prompt prediabetes screening. Seventeen percent of primary care providers could identify the correct laboratory parameters for diagnosing prediabetes based upon fasting glucose and hemoglobin A1c. While 88% of primary care providers reported close follow-up (within 6 months) of their patients who are prediabetic, only 45% knew the recommended minimum amount of weekly physical activity and 11% selected referral to a behavioral weight loss program as the initial management approach for patients who are prediabetic. Tseng et al. [6] concluded that primary care providers had substantial gaps in knowledge about prediabetes that need to be addressed in order to effectively manage and reduce the diabetes epidemic.
It is estimated that up to 80% of patients referred to outpatient physical therapy have diabetes, prediabetes, or diabetes risk factors [7]; thus, physical therapists are in an optimal position to intervene as members of a multidisciplinary team working to manage and reduce the diabetes epidemic [8]. More specifically, Harris-Hayes et al. [8] have recently advocated that physical therapists, as part of the multidisciplinary team, should be part of the front-line providers in diabetes prevention and management. In this role, physical therapists would provide guidance in physical activity participation for patients with or who are at risk for diabetes, by regularly screening patients for risk factors for diabetes and diabetes-related complications, and recommending regular physical activity as a key component for the treatment of chronic diseases in all patient interactions. Unfortunately, we were unable to locate any reports that have described physical therapists’ knowledge, practices, attitudes, and beliefs toward patients with prediabetes or diabetes. Understanding physical therapists’ knowledge about screening and diagnosing prediabetes is critical, especially if they will serve as front-line providers in diabetes prevention and management. More specifically, identifying any gaps in their knowledge could inform the provision of education and resources for physical therapists to enable them to appropriately recognize and manage prediabetes. Therefore, the purpose of this study was to assess the knowledge, practices, attitudes, and beliefs of private practice physical therapists toward patients with prediabetes.
Materials and methods
Study design
This cross-sectional study obtained ethical ap-proval from the Human Subjects Research Review Committee at Daemen College, Amherst, NY. Permission was additionally granted to purchase the air mailing addresses of physical therapists from the Private Practice section of the American Physical Therapy Association after they had reviewed and approved the study protocol. Electronic mailing addresses of individuals from this organization were not available for purchase.
Research instrument
The paper based survey completed by participants in this study had previously been used by Tseng et al. [6] to assess knowledge, practices, attitudes and beliefs of primary care physicians toward patients with prediabetes. More specifically, the survey, which was anonymous, assessed (1) knowledge of risk factors that should prompt prediabetes screening, laboratory criteria for diagnosing prediabetes, and guidelines on recommended therapy for prediabetes; (2) management of prediabetes; and (3) attitudes and beliefs about prediabetes. Except for some very subtle modifications to ensure the survey was consistent with the scope of practice for private practice physical therapists in the United States (Appendix 1), participants in our study completed the same survey developed by Tseng et al. [6] primarily to allow comparison with their results.
When assessing risk factors for prediabetes screening, private practice physical therapists were given a list of potential risk factors from the American Diabetes Association and asked to select risk factors that might prompt them to refer a patient for diabetes screening [5, 9]. Private practice physical therapists were also asked to select which guidelines they use for prediabetes screening. When evaluating laboratory criteria for diagnosing prediabetes and diabetes, private practice physical therapists were asked to identify laboratory tests that are used to diagnose prediabetes or diabetes. Furthermore, private practice physical therapists were asked to identify the numerical values corresponding to the upper and lower limits of the laboratory criteria for diagnosing prediabetes based on fasting glucose (possible answer range: 70–160 mg/dl in 2 mg/dl increments; correct answer range: 100–125 mg/dl) and hemoglobin A1c (possible answer range: 5.0–7.0% in 0.1% increments; correct answer range: 5.7–6.4%).
For guideline recommendations for the treatment of prediabetes, private practice physical therapists were asked to select the appropriate recommendations for minimum weight loss (correct answer range: 5 to 7% of body weight) and the minimum amount of weekly physical activity (correct answer: 150 minutes per week) from the 2017 guidelines from the American Diabetes Association [5]. Regarding management practices for patients with prediabetes, private practice physical therapists were asked to identify the best initial management approach for a patient with prediabetes (correct answer: refer the patient to a behavioral weight loss program). Appropriate timelines were assessed for repeat laboratory work and physician follow-up for patients with pre-diabetes (correct answer range: 3 to 6 months), and other management practices, including the use of metformin for patients with prediabetes. Correct responses for these inquiries were from the 2017 guidelines from the American Diabetes Association [5].
Attitudes and beliefs about prediabetes and management of prediabetes were assessed by asking private practice physical therapists to rate their attitudes and beliefs regarding identification of prediabetes, effectiveness of lifestyle modification for reducing risk of progression from prediabetes to diabetes, use of metformin for patients with prediabetes, barriers to lifestyle modification, and the effectiveness of a variety of interventional approaches to manage patients with prediabetes. These attitudes and beliefs were assessed using a 5-point Likert scale with answers ranging from “strongly agree” to “strongly disagree”. Private practice physical therapists were also asked to report relevant demographic information, including education and clinical practice experience (i.e., years practiced as a physical therapist, current primary position, percentage of time currently spent in clinical practice).
Participants/Recruitment
A total of 1000 private practice physical therapists were invited to participate in the study. They were selected for study in this current investigation based on the likelihood that their members would treat the intended patient population that would likely be at risk for pre-diabetes or currently being managed for diabetes. One thousand private practice physical therapists were selected for participation as this number of participants was generally consistent with several prior studies that have surveyed physical therapists on other important practice issues and had adequate response rates for analysis [10–15]. Participants were randomly selected for participation through a random number generator based upon current professional air mail distribution lists which were purchased through the Private Practice section of the American Physical Therapy Association. The list that was purchased included 4,167 members. Private practice physical therapists were initially contacted in March 2018 and surveys returned within 3 months were included in the analysis. Based on our pilot testing, it was expected that participants would require approximately 20 minutes to complete the entire survey; however, no time limit was imposed on the survey. Once consent was obtained and individuals completed the survey, they returned it to the primary investigator via a stamped envelope that was provided. The results of the survey were stored in a secure, password-protected database for subsequent analysis.
Participants were asked if they had previously read the research performed by Tseng et al. [6]. Those familiar with their research study were excluded from the data analysis, as the correct responses to each item were included in that research and participants could potentially be biased by the physician responses. To maximize participation, participants were not asked to complete the survey in a proctored setting (i.e., the exam is supervised by an approved, neutral person who ensures the identity of the individual taking the test and the integrity of the testing environment). However, participants were asked to complete the survey independently without the help of any outside resources (e.g. internet, textbook, etc).
Data analysis
Descriptive statistics were calculated for survey data as appropriate (frequencies for categorical data and means and standard deviations for continuous data) to determine the knowledge, practices, attitudes, and beliefs of physical therapists toward patients with prediabetes. Data analyses were performed using the Statistical Package for the Social Sciences program (version 24) (International Business Machines Corporation, Chicago, IL, USA).
Results
Demographic data
In total, 63 private practice physical therapists (response rate = 6.3%) completed the survey (34 males, 29 females; mean age: 52.8±11.5 years; mean number of years of clinical practice: 25.7±12.3 years). The general characteristics of the participants that completed the survey in terms of education and experience are shown in Table 1.
Characteristics of clinical experience and training for physical therapists (n = 63)
Characteristics of clinical experience and training for physical therapists (n = 63)
Seventy nine percent of private practice physical therapists agreed that identifying prediabetes in their patients is important for managing their health. Three percent of private practice physical therapists correctly identified all of the risk factors that should prompt prediabetes screening. On average, private practice physical therapists selected 6 out of the 12 correct risk factors for prediabetes screening. The most common risk factors identified were family history of diabetes (92%), being overweight (81%), sedentary lifestyle (78%), history of gestational diabetes (57%), and hypertension (56%). The least-commonly identified risk factors were age ≥45 (37%), dyslipidemia (33%), Hispanic ethnicity (22%), and Asian race (6%). Eleven percent of private practice physical therapists correctly identified all of the “medical” risk factors that should prompt prediabetes screening (i.e., age ≥45, body mass index ≥25 kg/m2, hypertension, dyslipidemia, heart disease, family history of diabetes, sedentary lifestyle, history of gestational diabetes) (Table 2).
Knowledge and practices regarding diabetes screening (n = 63)
Knowledge and practices regarding diabetes screening (n = 63)
While 73% of private practice physical therapists could identify the correct laboratory test to screen for diabetes, less than 10% of private practice physical therapists could identify the correct laboratory parameters for diagnosing prediabetes and diabetes (Table 2). While 78% of private practice physical therapists selected referral to a counselor for diet changes and physical activity to lose weight as the recommended initial management approach to prediabetes, only 2% and 22% of private practice physical therapists could identify the correct weight loss (i.e., 5 to 7% of body weight) and physical activity (i.e., 150 minutes per week) recommendations, respectively (Table 2). Three percent of private practice physical therapists selected referral to a behavioral weight loss program as the recommended initial management approach to prediabetes (Table 3).
Knowledge, practices and beliefs regarding prediabetes management (n = 63). *More than one answer could be selected so totals are > 100%
Knowledge, practices and beliefs regarding prediabetes management (n = 63). *More than one answer could be selected so totals are > 100%
When asked about their initial management approach in their practice and with their current resources, private practice physical therapists most commonly selected counseling on diet changes and physical activity (49%), discuss starting metformin (29%), and referral to a nutritionist (21%). Regarding the correct identification for physician follow-up and repeat laboratory work for patients with prediabetes (i.e., 3 to 6 months), 43% and 40% of private practice physical therapists were correct in their response, respectively (Table 3).
Attitude and beliefs regarding prediabetes and its management
While 97% of private practice physical therapists believed that lifestyle modification can reduce the risk of diabetes in their patients with prediabetes, the majority of private practice physical therapists generally agreed that patient-related factors are important barriers to lifestyle changes. For example, barriers to lifestyle changes included a lack of motivation (84%), patients’ physical limitations in doing activity (84%), patients don’t think it is important to make changes (76%), and lack of nutrition resources (57%). Regarding interventions for improving prediabetes management, private practice physical therapists reported that improved access to diabetes prevention programs (87%), improved nutrition resources (83%), more time for counseling (81%), improved access to weight loss programs (76%), and more educational resources for patients (71%) would be helpful (Table 3).
Discussion
In this study, we identified a variety of domains that are lacking relative to private practice physical therapist knowledge and management practices for patients with prediabetes. First, very few private practice physical therapists were able to identify each of the risk factors that should lead to screening for prediabetes. Second, private practice physical therapists could not routinely identify the correct laboratory parameters for diagnosing prediabetes and diabetes, nor the appropriate time for physician follow-up and repeat laboratory work for patients with prediabetes. Third, private practice physical therapists had difficulty identifying the correct weight loss and physical activity recommendations, as well as appropriate initial management approach to prediabetes. These gaps in knowledge could inform the provision of education and resources for physical therapists to enable them to appropriately recognize and manage prediabetes.
The results of our study are consistent with those of Abaraogu et al. [16] and O’Donoghue et al. [17] who examined current assessment and management practices of several lifestyle related risk factors for non-communicable diseases for physical therapists in Nigeria and primary care physical therapists in the Republic of Ireland, respectively. The results of both studies determined that physical therapists most commonly assessed physical activity in their patients. However, physical therapists were generally inexperienced and inconsistent in evaluating and addressing the majority of other key lifestyle related risk factors (e.g., smoking, dietary status, alcohol consumption) for non-communicable diseases such as cardiovascular disease and type 2 diabetes. The primary reasons that lifestyle related risk factors were not assessed by physical therapists included a lack of time, limited knowledge and expertise, and the patient’s perceived lack of interest in changing their unhealthy behavior [16, 17]. Our findings are also in agreement with those of Tseng et al. [6], in that only a small number of primary care providers surveyed were able to identify all of the risk factors that should prompt prediabetes screening. The results of these studies suggest that strategies are required to improve the knowledge of physical therapists, physicians, nurse practitioners, and physician assistants about the assessment and management for patients who are prediabetic.
As noted by the American Physical Therapy Association [18], physical therapists can help people with diabetes improve or avoid related problems, and can teach sedentary people how to add physical activity to their lives in safe and effective ways. In the United States, diabetes is diagnosed by a physician; physical therapists are not able to order the tests required to assess blood glucose levels that are necessary to diagnose diabetes. Nonetheless, Harris-Hayes et al. [8] has recently advocated that physical therapists should be front-line providers in diabetes prevention and management by evaluating the symptoms and problems associated with diabetes. Then, after careful review of a patient’s record of blood glucose levels, they can design an individualized treatment program that addresses the patient’s problems and needs. The results of our study suggest that private practice physical therapists may need a more comprehensive understanding of the laboratory tests and values associated with diabetes in order to most effectively educate and care for patients with diabetes.
Despite evidence that early diagnosis and intervention of prediabetes can significantly reduce progression to type 2 diabetes, Karve and Hayward [22] determined that the majority of patients with prediabetes are actually undiagnosed and untreated with appropriate interventions. After studying 1,547 nondiabetic adults, they determined that only 5% of patients with prediabetes actually received a formal diagnosis from a physician. Additionally, the physician recommendation rates for exercise or diet were 32% and 34%, respectively. Among the patients who did exercise, only 49% reported exercising for at least 30 minutes daily. The authors noted that it is unclear if these findings are due to providers being unaware of the evidence, unconvinced by the evidence, or clinical inertia, which is defined as a failure to initiate or escalate therapy in those patients not achieving their blood glucose goals [23, 24]. Our study results, as well as those by Tseng et al. [6], would appear to support the hypothesis that providers may be unaware of the best current evidence for managing patients who are prediabetic.
The majority of private practice physical therapists who participated in this study (97%) generally agreed that lifestyle modification can reduce the risk of diabetes in their patients with prediabetes. However, survey participants identified several patient-related factors as important barriers to lifestyle changes such as a lack of motivation (84%), patients’ physical limitations in doing activity (84%), patients don’t think it is important to make changes (76%), and lack of nutrition resources (57%). Despite these patient-related barriers to lifestyle changes, the importance of lifestyle modification in reducing the risk of diabetes cannot be underestimated, as even subtle changes in health behaviors can have major influences on chronic diseases. In a study of 23,153 German participants aged 35 to 65 years who were followed for a mean of 7.8 years, Ford et al. [25] concluded that people who did not smoke, were physically active for 3.5 hours/week, had a body mass index < 30 kg/m2, and followed healthy dietary principles (high intake of fruits, vegetables, and whole-grain bread and low meat consumption) had a 78% lower risk of developing a chronic disease (e.g., diabetes, myocardial infarction, stroke, and cancer). More specifically, the risk of diabetes was reduced by 93% [25]. Future research on patient-related factors as barriers to lifestyle changes [26] and a more thorough understanding of patient perspectives will be important in effectively managing and preventing diabetes in the future.
Since 2003, the guidelines from the American Diabetes Association for patients with prediabetes have focused on lifestyle modification such as weight loss and exercise and recommendations for the use of metformin were added in 2007 [27]. In our survey, only 27% of private practice physical therapists were familiar with the guidelines from the American Diabetes Association for patients with prediabetes. The lack of familiarity with the American Diabetes Association guidelines and the knowledge gaps identified in this study may suggest limited exposure to these guidelines in the entry-level education of physical therapists and continuing education opportunities following graduation. Additionally, we are unaware of a physical therapy clinical practice guideline for patients with diabetes through one of the key professional physical therapy organizations. Thus, greater exposure of the American Diabetes Association guidelines in entry-level physical therapy education and post-graduate continuing education courses may be helpful. Also, a physical therapy clinical practice guideline for patients with diabetes may assist in improving knowledge of risk factors, diagnostic testing, and management strategies for patients with prediabetes.
Since chronic diseases like diabetes are strongly associated with risk factors or lifestyle behaviors, such as physical inactivity, unhealthy diet, and tobacco use, they are largely preventable [28–30]. Thus, to adequately address contemporary healthcare needs, including health promotion, wellness, and illness prevention, the global healthcare focus has shifted from an illness model to more of a health and wellness model [16, 17]. Accordingly, healthcare professionals, including physical therapists worldwide, will need to expand their practice from the treatment of disability and illness to more of a health and wellness focus which specifically addresses primary and secondary disease prevention [16, 32]. In order to do this, physical therapists need to have adequate knowledge of screening, diagnosis, and management of chronic diseases, like diabetes. The results of this study and others in countries other than the United States [16, 17] suggest that strategies are required to improve the knowledge of physical therapists in screening, diagnosis, and management of chronic diseases. An important initial step could include educating physical therapists globally on screening guidelines, diagnostic criteria and management options through high quality webinars and other forms of continuing education that focus on interprofessional and collaborative practice. Additionally, the role of institutions and professional societies (e.g., Irish Society of Chartered Physiotherapists, American Physical Therapy Association, etc.) in emphasizing the need to improve knowledge and address attitudes cannot be underestimated. With these strategies, physical therapists would be optimally positioned as part of the multidisciplinary team to effectively manage and reduce the diabetes epidemic.
There were several limitations to this study. First, we had a 6% response rate, which is lower than we expected for a nonincentivized survey [33]. This may have been due to the length of the survey and the perceived time required to complete it or a lack of interest in the topic of study. Additionally, those familiar with the research study by Tseng et al. [6] were excluded from the data analysis. Second, our data may reflect a selection bias; perhaps respondents with a special interest in diabetes were more likely to complete our survey. Thus, the findings may not generalize to other members of the profession, such as nonmembers of the Private Practice section of the American Physical Therapy Association. Third, to our knowledge, the instrument has not been formally evaluated for reliability. While the examination may appear to be generally valid on its face, it is not known if the results of this survey study accurately depict participants’ actual clinical practice patterns. Despite these limitations, the findings offer an initial novel representation of the knowledge, practices, attitudes, and beliefs of private practice physical therapists toward patients with prediabetes.
Conclusion
This study provides novel information regarding private practice physical therapist’s knowledge, practices, attitudes, and beliefs about prediabetes. Numerous gaps in knowledge were noted regarding risk factor identification, diagnostic testing strategies, appropriate weight loss and activity recommendations, and referral strategies for patients with prediabetes in the sample of private practice physical therapist’s included in this study. These results may have important implications for the education of private practice physical therapists, especially those providing care for patients without a referral who are at risk for diabetes.
